Healthcare Provider Details

I. General information

NPI: 1952308181
Provider Name (Legal Business Name): GARY RAY PROCTOR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/01/2005
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10199 SOUTHSIDE BLVD BLD 100 SUITE 300
JACKSONVILLE FL
32256-0758
US

IV. Provider business mailing address

140 CROSSTIDE CIR
PONTE VEDRA BEACH FL
32082-4028
US

V. Phone/Fax

Practice location:
  • Phone: 800-700-8646
  • Fax:
Mailing address:
  • Phone: 904-285-4715
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084F0202X
TaxonomyForensic Psychiatry Physician
License NumberME 71703
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberME 71703
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: